THIS APPLICATION IS FOR THE AUTHORITY TO PRESCRIBE INDEPENDENTLY AS AN ADVANCED PRACTICE NURSE. THIS IS NOT A LICENSE TO PRACTICE AS A NURSE PRACTITIONER OR CLINICAL NURSE SPECIALIST AS NO SUCH LICENSE EXISTS IN THE STATE OF INDIANA.

ALL APPLICANTS must mail a completed application along with the items listed below to the Indiana Professional Licensing Agency. You must hold an active, valid registered nurse license in Indiana or another state to be eligible for prescriptive authority.

The application requires you to indicate the category of Advanced Practice Nursing under which are applying for Prescriptive Authority: You must choose one of the following: Clinical Nurse Specialist; Nurse Practitioner; or Certified Nurse Midwife. Please note that if you are applying for prescriptive authority as a Certified Nurse Midwife, you still need a current Limited Nurse Midwife license in addition to your current RN license in order to practice nurse midwifery in the State of Indiana.

REQUIREMENTS

Mail completed, signed and dated application along with the items listed below to the Indiana Professional Licensing Agency.

Include a photograph, approximately 2 ½ x 3 ½ inches, head and shoulders view, black and white or color, of professional quality. Polaroid type or laminated photographs will not be accepted.Please place your signature on the front of your photograph.

Submit the $50.00 application fee made payable to the Indiana Professional Licensing Agency. Personal checks, cashier’s checks and money orders are acceptable. THE APPLICATION FEE IS NON-REFUNDABLE.

Enclose documentation of any legal name change if your name differs from that on any of your documents.Documentation may include a copy of your marriage license or divorce decree.

Enclose a copy of your current, unrestricted license as a registered nurse in the State of Indiana or another compact state. If you are in the process of applying for an Indiana license, please write "Pending Indiana Licensure" on the application in the space provided for listing of regulated health occupations.

Have your nursing program directly provide to the Indiana State Board of Nursing an official transcript showing successful completion of a graduate program offered by a college or university accredited by the Commission on Recognition of Postsecondary Accreditation. If you received a bachelor's degree rather than a graduate degree, you must submit proof of current national certification.

Submit proof of having successfully completed a graduate level pharmacology course consisting of at least two (2) semester hours of academic credit from a college or university accredited by the Commission on Recognition of Postsecondary Accreditation:

within five (5) years of the date of application; or

if the pharmacology course was completed more than five (5) years immediately preceding the date of filing the application, the applicant must submit proof of the following:

Completion of at least thirty (30) actual contact hours of continuing education during the two (2) years immediately preceding the date of the application, including a minimum of at least eight (8) actual contact hours of pharmacology, all of which must be approved by a nationally approved sponsor of continuing education for nurses; and

Prescriptive experience in another jurisdiction within the five (5) years immediately preceding the date of the application.

"OFFICIAL" MEANS THESE DOCUMENTS MUST BE AN ORIGINAL DOCUMENT PROVIDED BY THE ORIGINAL SOURCE.

If you answer "yes" to any questions on page 3 of the application, explain fully in a statement that includes all related details. Include the violation, location, date and disposition. If malpractice, provide the name(s) of the plaintiff(s).

Verification of Licensure form(s) must be completed by and received from every state where you hold or have held a license. This verification form must be sent to the state(s) other than Indiana to verify your license(s). CHECK WITH EACH STATE REGARDING THE FEE(S) CHARGED FOR THIS SERVICE.

Written Collaborative Practice Agreement(s) - (Template Collaborative Practice Agreement) - When submitting a collaborative practice agreement, please indicate whether it is a new collaborative practice agreement, a new collaborative practice agreement that is replacing an existing collaborative practice agreement, or if it is an addition to an existing collaborative practice agreement.

The written collaborative practice agreement sets forth the manner in which the Advanced Practice Nurse and Licensed Practitioner will cooperate, coordinate, and consult with each other in the provision of health care to patients. Collaborative practice agreements shall be in writing and shall also set forth provisions for the type of collaboration between the Advanced Practice Nurse and the Licensed Practitioner, and the reasonable and timely review by the Licensed Practitioner of the prescribing practices of the Advanced Practice Nurse. Specifically, the written practice agreement shall contain at least the following information:

Complete names, home and business addresses, zip codes and telephone numbers of the Licensed Practitioner and the Advanced Practice Nurse.

A list of all other offices or practice locations in addition to those listed in clause (1) where the Licensed Practitioner authorizes the Advanced Practice Nurse to prescribe.

All specialty or board certifications of the Licensed Practitioner and the Advanced Practice Nurse.

The specific manner of collaboration between the Licensed Practitioner and the Advanced Practice Nurse, including how the Licensed Practitioner and the Advanced Practice nurse will:

A description of the time and manner of the Licensed Practitioner's review of the Advanced Practice Nurse’s prescribing practices. The description shall include provisions that the Advanced Practice Nurse must submit documentation of the Advanced Practice Nurse’s prescribing practices to the Licensed Practitioner within seven (7) days. Documentation of prescribing practices shall include, but not be limited to, a least a five percent (5%) random sampling of the charts and medications prescribed for patients.

A list of all other written collaborative practice agreements including the Licensed Practitioner and Advanced Practice Nurse. For example, list any other Advanced Practice Nurse(s) with which this Licensed Practitioner may have a current agreement(s) and any other Licensed Practitioner with which this Advanced Practice Nurse applicant may have a current agreement(s).

The duration of the written collaborative practice agreement between the Licensed Practitioner and the Advanced Practice Nurse.

The collaborative practice agreement must have original signatures of the Licensed Practitioner and the Advanced Practice Nurse.

INDIANA STATE CONTROLLED SUBSTANCES REGISTRATION

If you are an Advanced Practice Nurse wanting to administer, dispense or procure controlled substances in Indiana, you must obtain an Indiana controlled substances registration (CSR). The application fee is $60.00 and can be made payable to the Indiana Professional Licensing Agency. You may send the CSR and prescriptive authority applications in together and include one check. THE APPLICATION FEE IS NON-REFUNDABLE. You must also obtain a federal Drug Enforcement Administration (DEA) registration. You must contact the DEA at (317) 226-7997 to obtain an application and any other information regarding that registration or visit their website.

A practitioner must hold one CSR in order to prescribe controlled substances in the State of Indiana. An additional, separate registration is required for each practice address at which a practitioner physically possesses controlled substances to administer or dispense. A separate registration is not required for each place where a practitioner merely prescribes controlled substances. One valid CSR is sufficient for a practitioner to prescribe controlled substances throughout the State.

Applicants must use an Indiana practice address when applying for a CSR. The CSR can only be mailed to the address submitted on the application and can only be issued to a street address. Addresses with a post office box will not be acceptable unless accompanied by a street address.

Questions about the application process should be directed to the nursing group at (317) 234-2043 or pla2@pla.in.gov

NOTICE

In compliance with Indiana Code 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become public record. Your examination scores and grade transcripts are confidential except in circumstances where their release is required by law, in which case you will be notified.

Pursuant to Section 7 of the Privacy Act of 1974, you are hereby given notice that disclosure of your U.S. Social Security number on your application is mandatory for the purpose of complying with IC 25-1-5-8 and IC 4-1-8-1 which provide that the Indiana Department of Revenue may obtain Social Security numbers from the Indiana Professional Licensing Agency for tax enforcement purposes. In addition, disclosing such number is mandatory in order for the licensing board or committee to comply with the requirements of the federal National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank 42 U.S.C. §1320(a)-7e(b), 5 USC §552a, 45 CFR Part 60.1, and 45 CFR Part 61.

Failure to disclose your U.S. social security number will result in the denial of your application

CONTINUING EDUCATION REQUIREMENTS

Advanced Practice Nurses with Prescriptive Authority must obtain at least thirty (30) hours of continuing education, at least eight (8) hours of which must be in pharmacology.

Applicants for renewal of Prescriptive Authority shall submit proof of completion of the mandatory continuing education at the time of renewal. Acceptable continuing education programs must be approved by a nationally approved sponsor of continuing education for nurses and approved by the Board.

If the applicant was initially granted prescriptive authority:

less than twelve (12) months before the expiration date of the prescriptive authority, no continuing education is required; or

at least twelve (12) months before the expiration date of the prescriptive authority, the applicant shall submit proof to the Board that the applicant has successfully completed at least fifteen (15) contact hours of continuing education. The hours must:

be completed after the prescriptive authority was granted and before the expiration of the prescriptive authority;

include at least four (4) contact hours of pharmacology; and

be approved by a nationally approved sponsor of continuing education for nurses, approved by the board, and listed by the Indiana Professional Licensing Agency as approved hours.